Fillable Hfs 3654 Illinois Template in PDF
Contents
The HFS 3654 form is an essential document for individuals seeking long-term care assistance in Illinois. This form, developed by the Illinois Department of Healthcare and Family Services, gathers critical financial information from applicants to assess their eligibility for medical assistance. It requires detailed responses to various questions, ensuring that all financial aspects are thoroughly documented. Applicants must provide information about their income, living arrangements, and any prior discussions with financial advisors or family members regarding their care needs. The form also asks about past tax filings, insurance policies, and any inheritances received within the last five years. Completing the HFS 3654 accurately is crucial, as it directly impacts the approval process for medical assistance. By following the instructions carefully and providing complete information, applicants can help streamline their application and increase their chances of receiving the support they need.
Things to Know About This Form
What is the purpose of the HFS 3654 form?
The HFS 3654 form is used by individuals applying for long-term care assistance in Illinois. It collects additional financial information necessary to determine eligibility for medical assistance. This form helps ensure that applicants meet the financial requirements for receiving support in a nursing home or similar facility.
Who needs to fill out the HFS 3654 form?
What information is required on the form?
Do I need to provide tax returns with the form?
What if I am currently living in a nursing home?
What should I do if I have a Power of Attorney (POA)?
What if I have been divorced?
Are there any requirements regarding insurance policies?
What if I received an inheritance?
Key takeaways
Filling out the HFS 3654 Illinois form can seem daunting, but understanding the key points can simplify the process. Here are some important takeaways:
- Complete All Sections: Ensure every question is answered completely and accurately. Incomplete forms can delay processing.
- Provide Necessary Documentation: If you have filed tax returns in the last 60 months, you must include copies of those returns for the last three years.
- List Previous Residences: If you are currently in a nursing home, be prepared to list your two previous addresses. This helps establish your living history.
- Financial Assistance Details: If someone helps you manage your finances, include their contact information and relationship to you. This is crucial for understanding your financial situation.
- Discuss Financial Planning: If you have consulted with a financial planner or attorney regarding nursing home care, mention their names and contact details. This can provide insight into your financial planning efforts.
- Insurance Information: If you have an insurance policy that covers nursing home care, provide details about the policy and who receives the payments.
- Report Inheritances: Disclose any inheritances received in the last 60 months, including the value and details about the deceased. This information is vital for assessing your financial eligibility.
By keeping these points in mind, you can navigate the HFS 3654 form with greater confidence and clarity.
Common mistakes
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Incomplete Responses: Many applicants fail to answer all questions fully. Every question must be addressed to ensure a complete application.
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Incorrect Tax Information: Applicants often neglect to provide copies of their tax returns for the required years. If you have filed a tax return in the last 60 months, include all relevant documents.
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Missing Signatures: Some individuals forget to sign the document. A signature is necessary for the application to be valid.
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Outdated Contact Information: Failing to provide current addresses or phone numbers can lead to communication issues. Ensure all contact details are accurate and up-to-date.
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Neglecting to List Previous Residences: Applicants sometimes overlook the requirement to list the last two places they lived before moving to a nursing home. This information is crucial for processing the application.
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Omitting Financial Assistance Details: If someone has been helping manage your finances, it is important to include their information. This includes any power of attorney or financial advisor.
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Failure to Provide Divorce Documentation: If you are divorced, applicants often forget to include a copy of the divorce decree. This is necessary for processing your application.
How to Fill Out Hfs 3654 Illinois
Completing the HFS 3654 form is an important step in the application process for long-term care assistance in Illinois. After gathering all necessary information, follow these steps to ensure the form is filled out correctly.
- Begin by filling in your applicant information. Include your last name, first name, middle initial, street address, city, state, county, zip code, and phone number.
- If your mailing address is different from your residential address, provide that information in the designated section.
- Answer the first question regarding whether you have filed a State or Federal income tax return in the last 60 months. If yes, specify the years and prepare to attach copies of your tax returns for the last three years.
- If you are currently living in a nursing home, list the last two places you lived before moving there. If you have not yet moved, provide the last two addresses prior to your current residence.
- Describe how you have paid for your nursing care before submitting this application.
- Indicate whether someone else has been assisting you with your financial matters. If yes, provide their name, address, phone number, and relationship to you. Specify if this person is your Power of Attorney (POA) and for what purpose (property or health).
- State whether you have discussed your need for nursing home care with a financial planner, attorney, or anyone else in the last 60 months. If yes, provide the names and contact information of those individuals.
- Indicate your marital status by selecting one of the options: single, married, divorced, widow/widower, or legally separated. If applicable, provide your current or most recent spouse’s name, address, phone number, and Social Security Number (SSN).
- If your spouse is deceased, include their date and place of death. If divorced, attach a copy of the divorce decree or provide the date and place of divorce.
- Answer whether you have an insurance policy that pays for nursing home care. If yes, list the policy number, insurance company, and who receives the payments.
- Finally, indicate if you have inherited money, property, or other assets in the last 60 months. If yes, provide details about the inheritance, including the amount, date received, and information about the deceased person.
After completing the form, review all entries for accuracy. Ensure you sign the document where indicated. Once finalized, submit the form along with any required attachments to the appropriate agency.
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